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s S63 126 QUALITY OF LIFE IN DIABETICS WITH MULTI-VESSEL CORONARY DISEASE: REAL-WORLD EXPERIENCE COMPARING PERCUTANEOUS CORONARY INTERVENTION AND CORONARY ARTERY BYPASS GRAFTING SURGERY B McGrath, CM Norris, RC Welsh, KR Bainey

Background: A recent study on exercise testing (ET) suggested that ST-segment changes in the right precordial leads (RPL) may increase its sensitivity substantially. However, this study looked at a highly selected population of patients who all underwent thallium-201 scintigraphy and coronary angiography. The present study evaluated the clinical utility of ST-segment changes in the RPL and lead aVR in an unselected population of patients undergoing ET. Methods: A total of 906 consecutive patients who received ET were included in the study. ET was done using the Bruce Protocol with a 12-lead electrocardiogram (ECG) substituting V 4 R and V 6 R for V 1 and V 6 . Leads V 1 and V 6 were selected for omission as these two leads hardly ever manifest changes in isolation. Substituting two leads would obviate the need for a more complex recording system, thus improving clinical utility. Results: On the basis of horizontal/downsloping ST-segment depression (STD) of 1.0 mm or more (the usually accepted criterion for a positive ET), 159 (17.5%) patients had a positive ET. In those patients with a negative ET (545 patients), 4 patients (0.7%) manifested STD and 5 patients (0.9%) manifested ST-segment elevation (STE) in leads V 4 R and/or V 6 R, respectively. Of note, 44.7% of the positive ET group had STE in lead aVR. Conclusion: The use of ST-segment changes in RPL during exercise stress testing does not appreciably change the test results of a standard ET. If one was to consider an additional marker, STE in aVR may be more useful, as it shows a stronger correlation with positive tests and does not require the recording of additional leads.

To determine whether the magnitude of ST-segment resolution after thrombolytic therapy (TT) predicts short- and long-term outcomes in an unselected population of patients with an acute myocardial infarction (AMI).Recent studies suggest that resolution of ST-segment elevation (STE) on the 2-hour post-TT electrocardiogram (ECG) is a useful predictor of prognosis. However, these studies were restricted to clinical trials where only 15% to 20% of the patients receiving TT were often enrolled.The present study evaluated an unselected consecutive group of patients who received TT. All clinical, investigational, and follow-up data had been collected in a prospective manner. The analysis of ECGs was done retrospectively with the reader blinded to the clinical course. STE at 80 milliseconds after the J point was measured on the baseline and 90-minute ECG using a hand-held caliper. The resolution of STE was categorized as complete (or=70%), partial (30% to70%), and none (30%) as has been done in previous studies.Three hundred fifty-two patients (250 men, 102 women; age, mean+/-SEM, 61.8+/-1.0 years; peak creatine kinase, 1938+/-185 micromol/L; door to needle time, 50.0+/-6 minutes,30 minutes, 50%;45 minutes, 70%) with AMIs who received TT were included in the study. Inhospital deaths and recurrent AMI/postinfarct angina revealed no significant association with increasing ST-segment resolution (P.05). A 70% or higher ST-segment resolution was associated with a significantly lower incidence of inhospital congestive heart failure (CHF) and CHF/death (P.05). Similarly, with a 70% or higher ST-segment resolution, there was a lower incidence in the 1-year outcomes of CHF and death/CHF. However the 1-year occurrences of unstable angina or recurrent AMIs taken singly did not bear a correlation to increasing magnitudes of ST-segment resolution (P.05). Although as a composite measure, there was an increasing trend with ST-segment resolution.Magnitude of ST-segment resolution after TT appears to demonstrate a dichotomous relationship to measured outcomes. Although there is a lower incidence of death/CHF with increasing ST-segment resolution, there appears to be a higher likelihood for recurrent AMI/unstable angina.

Although guidelines for selection of the appropriate pacing mode have been published, little data is available on how closely these are followed in the clinical setting. All 738 patients (men 412, women 326; age 73.4 +/- 0.46 years; range 19-101 years) who underwent pacemaker implantation from 1996 to 2000 were reviewed to determine if the appropriate mode was selected based on the ACC/AHA guidelines with the data collected prospectively. Demographic, investigational, and implantation data including the presence of sinus disease and/or atrioventricular block, diagnosis, indication for pacing, ACC/AHA class indication for device therapy, recommended ACC/AHA mode, implanted mode, and reason for not using the recommended mode were entered into an SPSS data base. Of 738 patients, 708 were cross-tabulated for a match to the guidelines of which 358 (50.6%) had a mode selected that did not conform. The reasons were advanced physical disability (16%), physician choice without identifiable reason (21%), rate modulation selected without identifiable indication (16%), DDD implanted instead of VDD (25%), advanced age (9%), rare need for pacing (6%), a need for specific device features (5%), and unstable stimulation thresholds or difficult venous access (2%). In the treatment of bradyarrhythmias, deviation from the ACC/AHA indicated mode occurred in a substantial proportion of pacing system implantations. However, in many, the deviation appeared appropriate considering the patient's clinical status. Nevertheless, in a smaller proportion of patients the deviation appeared inappropriate requiring rectification. The two outstanding categories were: (1) elderly denied a dual chamber system with no clinical explanation and (2) selection of rate-modulated devices without any indication of chronotropic incompetence.

Key initiatives jointly developed by the Government of Alberta and Alberta Health Services include improving cardiac health of Albertans, reducing stay in Emergency Departments for discharged patients, and providing a patientfocused health system that is accessible and sustainable for all Albertans. This is partly achieved by establishing clinical pathways to assist patient movement towards best possible outcomes, as well as expanding the scope of practice of Nurse Practitioners (NP).The Chest Pain Program Clinic (CPPC) was established in 2012, as a NP led outpatient clinic at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, within a collaborative practice model. Observations regarding prevalence of cardiovascular risk factors in this cohort, Emergency Department wait times, and continuing challenges facing the NP role will be presented. Findings suggest that the majority of patients were in the high risk category as per Framingham Risk Score, and had 2 or more risk factors for heart disease. Majority of the patients were discharged from the Emergency Departments within 8 hours of admission. Multiple challenges continue to exist for NP practice, and recommendations to possibly reduce these will be highlighted.

abetics, 19% Killip 4, and 77% undergoing primary PCI. The proportions taking 4/4 medication classes at discharge were 73.6% and 75.5% in intervention and control arms, respectively. At 12 months, proportions were 58.4% and 58.9% in the intervention and control group, respectively, (model-based OR 1.1, 95% CI 0.83-1.45). The process evaluation indicates that 51% of patients remembered receiving the intervention, and of these 52% took it for discussion with their health care provider. Patients reported that discontinuation of medication was most commonly at the direction of the internist/cardiologist (64%), and due to medication-related side-effects (62%). Discussion: DERLA-STEMI demonstrates the feasibility of recruiting and randomizing all eligible STEMI patients in a provincial health region. Preliminary results suggest low persistence to all 4 cardiac medication classes at 12-months. There was no significant difference in the use of guidelinerecommended medications post-STEMI in patients (and their family physicians) receiving delayed and repeated reminders as compared to usual care. HHS

Patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who undergo primary percutaneous coronary intervention (PCI) are most commonly treated with PCI to the culprit lesion only. Whether a strategy of complete revascularization in these patients is superior is unknown. We performed a meta-analysis comparing the benefits and risks of routine culprit-only PCI vs multivessel PCI in STEMI.MEDLINE, EMBASE, ISI Web of Science, and The Cochrane Register of Controlled Trials were searched from 1996 to January 2011. Relevant conference abstracts were searched from January 2002 to January 2011. Studies included STEMI with multivessel disease receiving primary PCI. The primary end point was long-term mortality. Data were combined using a fixed-effects model.Of 507 citations, 26 studies (3 randomized, 23 nonrandomized; 46,324 patients, 7886 multivessel PCI and 38,438 culprit-only PCI) were included. There was no significant difference in hospital mortality with multivessel PCI vs culprit-only PCI (odds ratio [OR] 1.11, 95% CI 0.98-1.25, P = .10 [randomized OR 0.24, 95% CI 0.06-0.91, P = .04; nonrandomized OR 1.12, 95% CI 1.00-1.27, P = .06]). However, if multivessel PCI during index catheterization was performed, hospital mortality was increased (OR 1.35, 95% CI 1.19-1.54, P.001). When multivessel PCI was performed as a staged procedure, hospital mortality was lower (OR 0.35, 95% CI 0.21-0.59; P.001; P interaction.001). Reduced long-term mortality (OR 0.74, 95% CI 0.65-0.85, P.001[randomized OR 0.61, 95% CI 0.28-1.33, P = .22; nonrandomized OR 0.75, 95% CI 0.65-0.86, P.001]) and repeat PCI (OR 0.65; 95% 0.46-0.90, P = .01[randomized OR 0.31, 95% CI 0.17-0.57, P.001; nonrandomized OR 0.88, 95% CI 0.59-1.31, P = .54]) were observed with multivessel PCI.Overall, staged multivessel PCI improved short- and long-term survival and reduced repeat PCI. Still, large randomized trials are required to confirm the benefits of staged multivessel PCI in STEMI.

Acute pericarditis is a common cardiovascular condition that is largely self-limited and effectively treated with nonsteroidal anti-inflammatory therapy. Despite simple and effective treatment, the diagnosis is often challenging because clinical symptoms can be misleading. Classically, acute pericarditis presents with sharp pleuritic chest pain that often is positional and varies with respiration. However, pericardial pain can also manifest as dull radiating chest discomfort that may mimic symptoms of myocardial ischemia. Physical examination at bedside can provide insight, most notably by the presence of a pericardial friction rub. However, only a minority of patients will have an audible rub at presentation.1,2 Auscultatory findings, if present, tend to be transient and variable. A study of a cohort of patients with acute pericarditis confirmed poor sensitivity of a pericardial friction rub, which was found in only 35% of the cohort.1 Despite the obvious limitations of physical findings, a pericardial friction rub is still one of the key diagnostic criteria.3 The characteristic electrocardiographic pattern is considered part of the diagnostic armamentarium, but its specificity is less clear.3 Because of global superficial myocardial inflammatory injury, serial electrocardiographic changes occur, usually commencing with PR depression (PR elevation in lead aVR), followed by diffuse ST-segment elevation. ST-segment elevation is noted in 65% to 70% of all cases of acute pericarditis, but it is often difficult to distinguish from ST-segment elevation myocardial infarction (STEMI).2,4 Although there can be differentiating electrocardiographic traits, providing a complete assessment may be difficult because many features in pericarditis are temporal.5,6 Reciprocal ST-segment changes may favor STEMI but are not always present. If an acute myocardial infarction (AMI) is considered as an alternative diagnosis, time for treatment may be limited, and additional strategies will be needed to determine the cause of the patient's condition. Cardiac biomarkers are frequently considered part of the diagnostic tool kit but are sometimes elevated in patients with acute pericarditis because of the inflammatory process involving the epicardium with subsequent myocardial necrosis. In fact, the incidence of elevated cardiac troponin I levels in patients with viral or idiopathic acute pericarditis has been reported to be 32.2%; of these patients, 23.7% had a troponin I level at admission that was beyond the AMI threshold.4 Furthermore, the temporal relationship of troponin elevation may be remarkably similar to that seen in AMI.4,7 The prognostic implication of elevated troponin levels is largely benign in acute pericarditis.4 An elevated cardiac biomarker in pericardial disease is not unusual and further complicates the diagnosis, raising suspicion for alternative etiologies of troponin elevation. See also page 11 Continued efforts in cardiac imaging have advanced assessments of pericardial disease. Chest computed tomography and cardiac magnetic resonance imaging offer superior image quality of the pericardium, although access is often limited and delayed. Echocardiography provides a relatively simple, noninvasive assessment of the pericardium at the time of patient presentation. Although the presence of a pericardial effusion is common, the absence of an effusion does not exclude diagnosis. Pericardial effusions are present in approximately 60% of cases of acute pericarditis, with 80% being mild, 10% being moderate, and 10% being severe.1 Thus, bedside echocardiography may be of particular benefit, especially if there are diagnostic dilemmas. If ischemia is suspected, regional wall motion abnormalities suggest an ischemic process. However, a substantial number of patients will have no identifying features, which may prompt further diagnostic modalities such as coronary angiography when the diagnosis is in doubt. In this issue of Mayo Clinic Proceedings, Salisbury et al8 provide great insight into both the frequency and the predictors of urgent coronary angiography in patients with acute pericarditis. This single-center retrospective analysis involved adult patients with viral or idiopathic pericarditis who had electrocardiographic changes that were potentially compatible with pericardial inflammation. Of a total of 238 patients, 16.8% underwent diagnostic coronary angiography; higher frequencies were noted in those with ST-segment elevation on their presenting electrocardiogram. Using univariate logistic regression, positive predictors of coronary angiography included typical angina, ST-segment elevation on the index electrocardiogram, previous percutaneous coronary intervention, elevated troponin T level on admission, diaphoresis, and male sex. Negative predictors were pleuritic or positional chest pain. The study by Salisbury et al is the most thorough study published that describes the frequency of coronary angiography in patients with acute pericarditis. Certainly, it adds to the growing body of evidence supporting alternative conditions that result in ST-segment elevation.9 Recently, a 14% “false-positive” rate of cardiac catheterization was found among patients with suspected STEMI.10 In patients with negative cardiac biomarkers, common causes include early repolarization, nondiagnostic electrocardiography, pericarditis, and previous myocardial infarction. In patients with positive cardiac biomarkers, stress cardiomyopathy, myocarditis, and STEMI due to emboli/spasm may present as alternative conditions.10 Performing urgent coronary angiography may be necessary when the diagnosis of acute pericarditis is uncertain. Symptoms may be misleading, and the electrocardiogram may be suggestive of an acute coronary syndrome (ACS). In fact, in approximately one-third of patients with myopericarditis, symptoms may suggest an ACS.11 In the current era of prompt reperfusion therapy, performing urgent angiography may be necessary to exclude AMI. The major complication rate of diagnostic cardiac catheterization for death, myocardial infarction, or stroke is well below 1%.12 Thus, the risk-benefit profile of patients with suspected ACS may favor diagnostic cardiac catheterization. The study by Salisbury et al reports a 4.8% rate of prior thrombolytic therapy in patients with acute pericarditis who were transferred to Mayo Clinic. Others have reported thrombolytic therapy rates as high as 19% for patients with myopericarditis that was mistaken for AMI.13 Given the heightened risk of pericardial effusion and tamponade after fibrinolytic therapy in patients with pericarditis, thrombolytic therapy should be avoided.14 In fact, patients in whom the diagnosis of pericarditis is uncertain should be promptly transferred for cardiac catheterization. The important observations by Salisbury et al remind us of the diagnostic challenges we still face with acute pericarditis.8 As such, AMI remains a plausible alternative diagnosis. Thus, diagnostic coronary angiography still plays an important role in discrimination and risk stratification. However, other diagnostic modalities should be considered during the acute phase of clinical presentation. Although electrocardiography may duplicate ST-segment ischemic changes, the progressive sequence of ST-T changes through 4 stages is well established.15 As well, PR-segment deviations are usually seen on the initial electrocardiogram and are present in approximately 80% of patients with acute pericarditis.5,16 Echocardiography may be useful for excluding STEMI, which often presents with wall motion abnormalities. In fact, Salisbury et al report an exceedingly low rate of regional wall motion abnormalities (4.5%) in approximately half of their patients with pericarditis who underwent echocardiography before receiving treatment.8 This rate is consistent with previously reported rates of 7% of patients with acute pericarditis having echocardiographic diffuse or localized abnormal ventricular wall motion.2,4 Cardiac biomarkers may be of limited benefit and should not be relied on once STEMI is considered because of restricted time assessments. Differentiating pericarditis from STEMI can be challenging. This situation is similar to removing a normal appendix so that a real case of acute appendicitis will not be overlooked. Occasionally, it is necessary to perform cardiac catheterization in a patient with acute pericarditis to rule out AMI.

Reperfusion in STEMI improves survival. Moreover, early reperfusion may abort the infarct and avoid significant myocardial necrosis. Yet, limited real world data exists and comparison between reperfusion strategies has not been performed. Accordingly, we assessed the frequency and outcomes of